Varicose Veins: Updates in Thermal and Non-thermal Ablation

Background

Chronic venous disease is common – it can affect up to 25% of women and 15% of men. Symptoms are variable, but it can be worsened, including the presence of ulcers, for those ignoring and delaying treatment.
Nowadays there is always debate and controversy among phlebologists and endovascular specialists as to which is the treatment of choice. What is superior, more effective, and more convenient for patients? Is it thermal ablation treatment (endovenous laser, radiofrequency, steam, or even microwave), or is it nonthermal ablation (glue, mechanochemical, or the old choice: ultrasound-guided foam sclerotherapy)?

Insights

Endovenous ablation therapy continues to evolve, especially with "mega" great saphenous veins, with an occlusion rate in up to 96% of cases during early follow-up. Using high-power laser therapy with a wavelength of 1940 nm, and the concept of flush endovenous ablation closure with no residual blind spot (as opposed to the classical ablation 2 cm from the saphenofemoral junction and saphenopopliteal junction) should be not touched.

Ablation under ultrasound guidance is important, but nevertheless in selected cases – especially severely torturous great saphenous veins, or even in morbid patients – utilizing fluoroscopy will be an additional tool to successfully complete and shorten the procedure time.

Take-home message

Mastering all techniques is highly recommended in this era, based on different levels of evidence. Thermal ablation is recommended in cases of intrafascial, straight, non-tortuous great saphenous vein and small saphenous veins with diameters larger than 10 mm. On the other hand, if great/small saphenous veins are extrafascial, superficial, tortuous, have presence of axial reflux, or if the patient is obese or very anxious, non-thermal ablation will be an excellent choice.